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CLINICAL GUIDELINE

2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary
A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With The American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons Writing Committee Members*: L. David Hillis, MD, FACC, Chair,y Peter K. Smith, MD, FACC, Vice Chair,*,y Jeffrey L. Anderson, MD, FACC, FAHA,*,z John A. Bittl, MD, FACC,x Charles R. Bridges, MD, ScD, FACC, FAHA,*,y John G. Byrne, MD, FACC,y Joaquin E. Cigarroa, MD, FACC,y Verdi J. DiSesa, MD, FACC,y Loren F. Hiratzka, MD, FACC, FAHA,y Adolph M. Hutter, Jr, MD, MACC, FAHA,y Michael E. Jessen, MD, FACC,*,y Ellen C. Keeley, MD, MS,y Stephen J. Lahey, MD,y Richard A. Lange, MD, FACC, FAHA,y,x Martin J. London, MD,k Michael J. Mack, MD, FACC,*,{ Manesh R. Patel, MD, FACC,y John D. Puskas, MD, FACC,*,y Joseph F. Sabik, MD, FACC,*,# Ola Selnes, PhD,y David M. Shahian, MD, FACC, FAHA,** Jeffrey C. Trost, MD, FACC,*,y Michael D. Winniford, MD, FACCy Alice K. Jacobs, MD, FACC, FAHA, Chair, Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect, Nancy Albert, PhD, CCNS, CCRN, FAHA, Mark A. Creager, MD, FACC, FAHA, Steven M. Ettinger, MD, FACC, Robert A. Guyton, MD, FACC, Jonathan L. Halperin, MD, FACC, FAHA, Judith S. Hochman, MD, FACC, FAHA, Frederick G. Kushner, MD, FACC, FAHA, E. Magnus Ohman, MD, FACC, William Stevenson, MD, FACC, FAHA, Clyde W. Yancy, MD, FACC, FAHA

ACCF/ AHA Task Force Members:

* Writing committee members are required to recuse themselves from voting on sections to which their specic relationships with industry and other entities may apply; see Appendix 1 for recusal information. y ACCF/AHA Representative. z ACCF/AHA Task Force on Practice Guidelines Liaison. x Joint Revascularization Section Author. k Society of Cardiovascular Anesthesiologists Representative. { American Association for Thoracic Surgery Representative. # Society of Thoracic Surgeons Representative. ** ACCF/AHA Task Force on Performance Measures Liaison. This document was approved by the American College of Cardiology Foundation Board of Trustees and American Heart Association Science Advisory and Coordinating Committee in July 2011, by the Society of Cardiovascular Anesthesiologists and Society of Thoracic Surgeons in August 2011, and by The American Association for Thoracic Surgery in September 2011. The American Association of Thoracic Surgery requests that this document be cited as follows: Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA guideline for coronary artery

bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2012;143:4-34. This article is copublished in Circulation, Anesthesia & Analgesia, and the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org), and the American Heart Association (my.americanheart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com. Permissions: Multiple copies, modication, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of The American Association for Thoracic Surgery. Please contact healthpermissions@ elsevier.com. 0022-5223/$36.00 Copyright 2012 by The American Association for Thoracic Surgery and the American Heart Association, Inc. doi:10.1016/j.jtcvs.2011.10.015

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TABLE OF CONTENTS
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.1. 1.2. 1.3. Methodology and Evidence Review . . . . . . . . . . . . . . 8 Organization of the Writing Committee. . . . . . . . . . . . 8 Document Review and Approval . . . . . . . . . . . . . . . . 8

5.6. Perioperative Myocardial Dysfunction . . . . . . . . . . . . 17

5.6.1.

Transfusion . . . . . . . . . . . . . . . . . . . . . . .17

5.7. Perioperative Dysrhythmias . . . . . . . . . . . . . . . . . . . 17 5.8. Perioperative Bleeding/Transfusion . . . . . . . . . . . . . . 17

6. Specific Patient Subsets: Recommendations . . . . . . . . . .17


6.1. Anomalous Coronary Arteries . . . . . . . . . . . 6.2. Patients With Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency . . . . . . . . . 6.3. Patients With End-Stage Renal Disease on Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4. Patients With Concomitant Valvular Disease . 6.5. Patients With Previous Cardiac Surgery. . . . . . . . . . . 17 . . . . . . 17 . . . . . . 18 . . . . . . 18 . . . . . . 18

2.

Procedural Considerations: Recommendations . . . . . . . . 8


2.1. 2.2. 2.3. 2.4. 2.5. Anesthetic Considerations . . . . . . . . . . . . . . . . . Bypass Graft Conduit . . . . . . . . . . . . . . . . . . . . Intraoperative Transesophageal Echocardiography. Preconditioning/Management of Myocardial Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Subsets . . . . . . . . . . . . . . . . . . . . . . . . ....8 ....9 ....9 ....9 ....9

Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Appendix 1. Author Relationships With Industry and Other Entities (Relevant). . . . . . . . . . . . .30 Appendix 2. Reviewer Relationships With Industry and Other Entitites (Relevant) . . . . . . . . . . . .32

2.5.1. 2.5.2. 2.5.3. 2.5.4. 3.

CABG in Patients With Acute Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . Life-Threatening Ventricular Arrhythmias . Emergency CABG After Failed PCI . . . . . CABG in Association With Other Cardiac Procedures. . . . . . . . . . . . . . . . . . . . . . .

. 9 .10 .10 .10

CAD Revascularization: Recommendations . . . . . . . . . .10


3.1. 3.2. 3.3. 3.4. Heart Team Approach to Revascularization Decisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . Revascularization to Improve Survival. . . . . . . . Revascularization to Improve Symptoms . . . . . . Clinical Factors That May Influence the Choice of Revascularization . . . . . . . . . . . . . . . . . . . . . . . . 12 . . . . 12 . . . . 13 . . . . 13

PREAMBLE The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benets and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHATask Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice. Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specic data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; 5

3.4.1.
3.5.

Dual Antiplatelet Therapy Compliance and Stent Thrombosis . . . . . . . . . . . . . . . . . . .13

Hybrid Coronary Revascularization. . . . . . . . . . . . . . 13

4.

Perioperative Management: Recommendations . . . . . . . .14


4.1. 4.2. 4.3. 4.4. 4.5. 4.6. Preoperative Antiplatelet Therapy . . . . . . . . . . Postoperative Antiplatelet Therapy . . . . . . . . . Management of Hyperlipidemia . . . . . . . . . . . Hormonal Manipulation. . . . . . . . . . . . . . . . . Perioperative Beta Blockers . . . . . . . . . . . . . . Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers. . . . . . . . . . . . 4.7. Smoking Cessation . . . . . . . . . . . . . . . . . . . . 4.8. Emotional Dysfunction and Psychosocial Considerations . . . . . . . . . . . . . . . . . . . . . . . 4.9. Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . 4.10. Perioperative Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 14 14 14 14

. . . . . 15 . . . . . 15 . . . . . 15 . . . . . 15 . . . . . 15

4.10.1. Electrocardiographic Monitoring. . . . . . . .15 4.10.2. Pulmonary Artery Catheterization . . . . . . .15 4.10.3. Central Nervous System Monitoring . . . . .15 5. CABG-Associated Morbidity and Mortality: Occurrence and Prevention: Recommendations . . . . . . . .16
5.1. Public Reporting of Cardiac Surgery Outcomes . . . . . 16

5.1.1.
5.2. 5.3. 5.4. 5.5.

Use of Outcomes or Volume as CABG Quality Measures . . . . . . . . . . . . . . . . . . .16


. . . . 16 . . . . 16 . . . . 16 . . . . 17

Use of Epiaortic Ultrasound Imaging to Reduce Stroke Rates. . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Preoperative Carotid Artery Noninvasive Screening in CABG Patients . . . . . Mediastinitis/Perioperative Infection . . . . . . . . . Renal Dysfunction . . . . . . . . . . . . . . . . . . . . .

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TABLE 1. Applying classication of recommendations and level of evidence

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/efcacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. yFor comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specic modiers, comorbidities, and issues of patient preference that may inuence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efcacy and outcomes constitute the primary basis for the recommendations contained herein. In analyzing the data and developing recommendations and supporting text, the writing committee uses evidencebased methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the 6

size of the treatment effect considering risks versus benets in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specic denitions that are included in Table 1. Studies are identied as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked

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as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of no benet or is associated with harm to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only. In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as dened by ACCF/AHA guideline-recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines. Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specic COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential inuence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the ndings should inform a specic recommendation. The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specic diseases or conditions. The guidelines attempt to dene practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding the care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identied within each respective guideline when appropriate.

Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patients active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benets, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benet-to-risk ratio may be lower. The Task Force makes every effort to avoid actual, potential, or perceived conicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA denition of relevance). These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a condential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must rescue themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors and peer reviewers RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members comprehensive disclosure informationincluding RWI not pertinent to this documentis available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guide lines-and-Documents-Task-Forces.aspx. The work of the writing committee was supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity. In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, evidence tables (with references linked to abstracts in PubMed) have been added. In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the ACCF/AHA 7

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guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated. The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are ofcial policy of both the ACCF and AHA. Alice K. Jacobs, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice Guidelines 1. INTRODUCTION 1.1. Methodology and Evidence Review Whenever possible, the recommendations listed in this document are evidence based. Articles reviewed in this guideline revision covered evidence from the past 10 years through January 2011, as well as selected other references through April 2011. Searches were limited to studies, reviews, and evidence conducted in human subjects that were published in English. Key search words included but were not limited to: analgesia, anastomotic techniques, antiplatelet agents, automated proximal clampless anastomosis device, asymptomatic ischemia, Cardica C-port, cost effectiveness, depressed left ventricular (LV) function, distal anastomotic techniques, direct proximal anastomosis on aorta, distal anastomotic devices, emergency coronary artery bypass graft (CABG) and ST-elevation myocardial infarction (STEMI), heart failure, interrupted sutures, LV systolic dysfunction, magnetic connectors, PAS-Port automated proximal clampless anastomotic device, patency, proximal connectors, renal disease, sequential anastomosis, sternotomy, symmetry connector, symptomatic ischemia, proximal connectors, sequential anastomosis, T grafts, thoracotomy, U-clips, Ventrica Magnetic Vascular Port system, Y grafts. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative but not all-inclusive. The guideline is focused on the safe, appropriate, and efcacious performance of CABG. The STEMI, percutaneous coronary intervention (PCI), and CABG guidelines were written concurrently, with additional collaboration from the Stable Ischemic Heart Disease (SIHD) guideline writing committee. This allowed greater collaboration among the different writing committees on topics such as PCI in STEMI and revascularization strategies in patients with coronary artery disease (CAD) (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures). In accordance with the direction of the Task Force and feedback from readers, in this iteration of the guideline, the amount of text has been shortened, and emphasis has been placed on summary statements rather than detailed 8

discussion of numerous individual trials. Online supplemental evidence and summary tables have been created to document the studies and data considered for new or changed guideline recommendations. Because the executive summary contains only the recommendations, the reader is encouraged to consult the full-text guideline4 for additional detail on the recommendations and guidance on the care of the patient undergoing CABG. 1.2. Organization of the Writing Committee The committee was composed of acknowledged experts in CABG, interventional cardiology, general cardiology, and cardiovascular anesthesiology. The committee included representatives from the ACCF, AHA, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons (STS). 1.3. Document Review and Approval This document was reviewed by 2 ofcial reviewers, each nominated by both the ACCF and the AHA, as well as 1 reviewer each from the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS, as well as members from the ACCF/AHA Task Force on Data Standards, ACCF/AHA Task Force on Performance Measures, ACCF Surgeons Scientic Council, ACCF Interventional Scientic Council, and Southern Thoracic Surgical Association. All information on reviewers RWIs was distributed to the writing committee and is published in this document (Appendix 2. This document was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS. 2. PROCEDURAL CONSIDERATIONS: RECOMMENDATIONS 2.1. Anesthetic Considerations Class I
1. Anesthetic management directed toward early postoperative extubation and accelerated recovery of low- to medium-risk patients undergoing uncomplicated CABG is recommended.5-7 (Level of Evidence: B) 2. Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.8-12 (Level of Evidence: B) 3. Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication).13-16 (Level of Evidence: B) 4. A fellowship-trained cardiac anesthesiologist (or experienced board-certied practitioner) credentialed in the use of perioperative transesophageal echocardiography is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk.17-19 (Level of Evidence: C)

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Class IIa
1. Volatile anesthestic-based regimens can be useful in facilitating early extubation and reducing patient recall.6,20-22 (Level of Evidence: A)

2. Intraoperative transesophageal echocardiography should be performed in patients undergoing concomitant valvular surgery.45,47 (Level of Evidence: B)

Class IIb
1. The effectiveness of high thoracic epidural anesthesia/analgesia for routine analgesic use is uncertain.23-26 (Level of Evidence: B)

Class IIa
1. Intraoperative transesophageal echocardiography is reasonable for monitoring of hemodynamic status, ventricular function, regional wall motion, and valvular function in patients undergoing CABG.46,48-53 (Level of Evidence: B)

Class III: Harm


1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.27,28 (Level of Evidence: B) 2. Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C)

2.4. Preconditioning/Management of Myocardial Ischemia Class I


1. Management targeted at optimizing the determinants of coronary arterial perfusion (eg, heart rate, diastolic or mean arterial pressure, and right ventricular or LV end-diastolic pressure) is recommended to reduce the risk of perioperative myocardial ischemia and infarction.54-58 (Level of Evidence: B)

2.2. Bypass Graft Conduit Class I


1. If possible, the left internal mammary artery (LIMA) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD artery is indicated.29-32 (Level of Evidence: B)

Class IIa
1. Volatile-based anesthesia can be useful in reducing the risk of perioperative myocardial ischemia and infarction.59-62 (Level of Evidence: A)

Class IIa
1. The right internal mammary artery is probably indicated to bypass the LAD artery when the LIMA is unavailable or unsuitable as a bypass conduit. (Level of Evidence: C) 2. When anatomically and clinically suitable, use of a second internal mammary artery to graft the left circumex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention.33-37 (Level of Evidence: B)

Class IIb
1. The effectiveness of prophylactic pharmacological therapies or controlled reperfusion strategies aimed at inducing preconditioning or attenuating the adverse consequences of myocardial reperfusion injury or surgically induced systemic inammation is uncertain.63-70 (Level of Evidence: A) 2. Mechanical preconditioning might be considered to reduce the risk of perioperative myocardial ischemia and infarction in patients undergoing off-pump CABG.71-73 (Level of Evidence: B) 3. Remote ischemic preconditioning strategies using peripheralextremity occlusion/reperfusion might be considered to attenuate the adverse consequences of myocardial reperfusion injury.74-76 (Level of Evidence: B) 4. The effectiveness of postconditioning strategies to attenuate the adverse consequences of myocardial reperfusion injury is uncertain.77,78 (Level of Evidence: C)

Class IIb
1. Complete arterial revascularization may be reasonable in patients less than or equal to 60 years of age with few or no comorbidities. (Level of Evidence: C) 2. Arterial grafting of the right coronary artery may be reasonable when a critical (90%) stenosis is present.32,36,38 (Level of Evidence: B) 3. Use of a radial artery graft may be reasonable when grafting left-sided coronary arteries with severe stenoses (>70%) and right-sided arteries with critical stenoses (90%) that perfuse LV myocardium.39-44 (Level of Evidence: B)

Class III: Harm


1. An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%).32 (Level of Evidence: C)

2.5. Clinical Subsets 2.5.1. CABG in Patients With Acute Myocardial Infarction Class I
1. Emergency CABG is recommended in patients with acute myocardial infarction (MI) in whom (1) primary PCI has failed or cannot be performed, (2) coronary anatomy is suitable for CABG, and (3) persistent ischemia of a signicant area of myocardium at rest and/ or hemodynamic instability refractory to nonsurgical therapy is present.79-83 (Level of Evidence: B) 2. Emergency CABG is recommended in patients undergoing surgical repair of a postinfarction mechanical complication of MI, such as ventricular septal rupture, mitral valve insufciency because of papillary muscle infarction and/or rupture, or free wall rupture.84-88 (Level of Evidence: B)

2.3. Intraoperative Transesophageal Echocardiography Class I


1. Intraoperative transesophageal echocardiography should be performed for evaluation of acute, persistent, and life-threatening hemodynamic disturbances that have not responded to treatment.45,46 (Level of Evidence: B)

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3. Emergency CABG is recommended in patients with cardiogenic shock and who are suitable for CABG irrespective of the time interval from MI to onset of shock and time from MI to CABG.82,89-91 (Level of Evidence: B) 4. Emergency CABG is recommended in patients with life-threatening ventricular arrhythmias (believed to be ischemic in origin) in the presence of left main stenosis greater than or equal to 50% and/ or 3-vessel CAD.92 (Level of Evidence: C)

Class IIb
1. Emergency CABG might be considered after failed PCI for hemodynamic compromise in patients with previous sternotomy. (Level of Evidence: C)

Class III: Harm


1. Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion. (Level of Evidence: C) 2. Emergency CABG should not be performed after failed PCI if revascularization is impossible because of target anatomy or a no-reow state. (Level of Evidence: C)

Class IIa
1. The use of CABG is reasonable as a revascularization strategy in patients with multivessel CAD with recurrent angina or MI within the rst 48 hours of STEMI presentation as an alternative to a more delayed strategy.79,81,83,93 (Level of Evidence: B) 2. Early revascularization with PCI or CABG is reasonable for selected patients greater than 75 years of age with ST-segment elevation or left bundle branch block who are suitable for revascularization irrespective of the time interval from MI to onset of shock.94-98 (Level of Evidence: B)

2.5.4. CABG in Association With Other Cardiac Procedures Class I


1. CABG is recommended in patients undergoing noncoronary cardiac surgery with greater than or equal to 50% luminal diameter narrowing of the left main coronary artery or greater than or equal to 70% luminal diameter narrowing of other major coronary arteries. (Level of Evidence: C)

Class III: Harm


1. Emergency CABG should not be performed in patients with persistent angina and a small area of viable myocardium who are stable hemodynamically. (Level of Evidence: C) 2. Emergency CABG should not be performed in patients with noreow (successful epicardial reperfusion with unsuccessful microvascular reperfusion). (Level of Evidence: C)

Class IIa
1. The use of the LIMA is reasonable to bypass a signicantly narrowed LAD artery in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C) 2. CABG of moderately diseased coronary arteries (>50% luminal diameter narrowing) is reasonable in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C)

2.5.2. Life-Threatening Ventricular Arrhythmias Class I


1. CABG is recommended in patients with resuscitated sudden cardiac death or sustained ventricular tachycardia thought to be caused by signicant CAD (50% stenosis of left main coronary artery and/or 70% stenosis of 1, 2, or all 3 epicardial coronary arteries) and resultant myocardial ischemia.92,99,100 (Level of Evidence: B)

3. CAD REVASCULARIZATION: RECOMMENDATIONS Recommendations and text in this section are the result of extensive collaborative discussions between the PCI and CABG writing committees as well as key members of the SIHD and Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) writing committees. Certain issues, such as older versus more contemporary studies, primary analyses versus subgroup analyses, and prospective versus post hoc analyses, have been carefully weighed in designating COR and LOE; they are addressed in the appropriate corresponding text.4 The goals of revascularization for patients with CAD are to (1) to improve survival and (2) to relieve symptoms. The following text contains recommendations for revascularization toimprove survival and symptoms. These recommendations are summarized in Tables 2 and 3. Revascularization recommendations in this section are predominantly based on studies of patients with symptomatic SIHD and should be interpreted in this context. As discussed later in this section, recommendations on the type of revascularization are, in general, applicable to patients with UA/NSTEMI. In some cases (eg, unprotected left main

Class III: Harm


1. CABG should not be performed in patients with ventricular tachycardia with scar and no evidence of ischemia. (Level of Evidence: C)

2.5.3. Emergency CABG After Failed PCI Class I


1. Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk.101,102 (Level of Evidence: B) 2. Emergency CABG is recommended after failed PCI for hemodynamic compromise in patients without impairment of the coagulation system and without a previous sternotomy.101,103,104 (Level of Evidence: B)

Class IIa
1. Emergency CABG is reasonable after failed PCI for retrieval of a foreign body (most likely a fractured guidewire or stent) in a crucial anatomic location. (Level of Evidence: C) 2. Emergency CABG can be benecial after failed PCI for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy. (Level of Evidence: C)

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TABLE 2. Revascularization to improve survival compared with medical therapy

CABG, Coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not applicable; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/nonST-elevation myocardial infarction; UPLM, unprotected left main; VT, ventricular tachycardia. *In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI155,168-175 (Class IIa/LOE: B).

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TABLE 3. Revascularization to improve symptoms with signicant anatomic (50% left main or 70% nonleft main CAD) or physiological (FFR0.80) coronary artery stenoses

CABG, Coronary artery bypass graft; CAD, coronary artery disease; COR, class of recommendation; FFR, fractional ow reserve; GDMT, guideline-directed medical therapy; LOE, level of evidence; N/A, not applicable; PCI, percutaneous coronary intervention; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TMR, transmyocardial laser revascularization.

CAD), specic recommendations are made for patients with UA/NSTEMI or STEMI. 3.1. Heart Team Approach to Revascularization Decisions Class I
1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.105-107 (Level of Evidence: C)

the culprit lesion and the patient is not a candidate for CABG.111,127,129-131,136,137,139,140,142 (Level of Evidence: B) 3. PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary ow is less than Thrombolysis In Myocardial Infarction grade 3, and PCI can be performed more rapidly and safely than CABG.124,143,144 (Level of Evidence: C)

Class IIb
1. PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with signicant (50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good longterm outcome (eg, low-intermediate SYNTAX score of<33, bifurcation left main CAD); and (2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%).108,110,111,122-140,145 (Level of Evidence: B)

Class IIa
1. Calculation of the STS and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD.107-114 (Level of Evidence: B)

3.2. Revascularization to Improve Survival Left Main CAD Revascularization Class I


1. CABG to improve survival is recommended for patients with signicant (50% diameter stenosis) left main coronary artery stenosis.115-121 (Level of Evidence: B)

Class III: Harm


1. PCI to improve survival should not be performed in stable patients with signicant (50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG.108,110,111,115-123 (Level of Evidence: B)

Class IIa
1. PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with signicant (50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome eg, a low SYNTAX score [22], ostial or trunk left main CAD); and (2) clinical characteristics that predict a signicantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality 5%).108,110,111,122-140,168 (Level of Evidence: B) 2. PCI to improve survival is reasonable in patients with UA/ NSTEMI when an unprotected left main coronary artery is

Non-Left Main CAD Revascularization Class I


1. CABG to improve survival is benecial in patients with signicant (70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal LAD artery) or in the proximal LAD plus 1 other major coronary artery.117,121,146-149 (Level of Evidence: B) 2. CABG or PCI to improve survival is benecial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by signicant (70% diameter) stenosis in a major coronary artery. (CABG Level of Evidence: B;99,150,152 PCI Level of Evidence: C150)

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Class IIa
1. CABG to improve survival is reasonable in patients with signicant (70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium.153-156 (Level of Evidence: B) 2. CABG to improve survival is reasonable in patients with mildmoderate LV systolic dysfunction (ejection fraction 35% to 50%) and signicant (70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization.121,157-161 (Level of Evidence: B) 3. CABG with a LIMA graft to improve survival is reasonable in patients with signicant (70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia.30,31,121,148 (Level of Evidence: B) 4. It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG.123,138,148,164-165 (Level of Evidence: B) 5. CABG is probably recommended in preference to PCI to improve survival in patients with multivessel CAD and diabetes mellitus, particularly if a LIMA graft can be anastomosed to the LAD artery.155,168-175 (Level of Evidence: B)

Class IIa
1. CABG or PCI to improve symptoms is reasonable in patients with 1 or more signicant (70% diameter) coronary artery stenoses and unacceptable angina for whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences. (Level of Evidence: C) 2. PCI to improve symptoms is reasonable in patients with previous CABG, 1 or more signicant (70% diameter) coronary artery stenoses associated with ischemia, and unacceptable angina despite GDMT.180,183,186 (Level of Evidence: C) 3. It is reasonable to choose CABG over PCI to improve symptoms in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG.123,138,148,164-165 (Level of Evidence: B)

Class IIb
1. CABG to improve symptoms might be reasonable for patients with previous CABG, 1 or more signicant (70% diameter) coronary artery stenoses not amenable to PCI, and unacceptable angina despite GDMT.187 (Level of Evidence: C) 2. Transmyocardial laser revascularization performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting.203-207 (Level of Evidence: B)

Class IIb
1. The usefulness of CABG to improve survival is uncertain in patients with signicant (70%) stenoses in 2 major coronary arteries not involving the proximal LAD artery and without extensive ischemia.148 (Level of Evidence: C) 2. The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease.117,146,148,176 (Level of Evidence: B) 3. CABG might be considered with the primary or sole intent of improving survival in patients with SIHD with severe LV systolic dysfunction (ejection fraction<35%) whether or not viable myocardium is present.121,157-161,177,178 (Level of Evidence: B) 4. The usefulness of CABG or PCI to improve survival is uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing.179-187 (Level of Evidence: B)

Class III: Harm


1. CABG or PCI to improve symptoms should not be performed in patients who do not meet anatomic (50% left main or 70% non-left main stenosis) or physiological (eg, abnormal fractional ow reserve) criteria for revascularization. (Level of Evidence: C)

3.4. Clinical Factors That May Inuence the Choice of Revascularization 3.4.1. Dual Antiplatelet Therapy Compliance and Stent Thrombosis Class III: Harm
1. PCI with coronary stenting (bare-metal stent or drug-eluting stent) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy for the appropriate duration of treatment based on the type of stent implanted.208-211 (Level of Evidence: B)

Class III: Harm


1. CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with SIHD with 1 or more coronary stenoses that are not anatomically or functionally signicant (eg, <70% diameter non-left main coronary artery stenosis, fractional ow reserve >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumex or right coronary artery, or subtend only a small area of viable myocardium.121,146,153,154,188-192 (Level of Evidence: B)

3.5. Hybrid Coronary Revascularization Class IIa


1. Hybrid coronary revascularization (dened as the planned combination of LIMA-to-LAD artery grafting and PCI of 1 non-LAD coronary arteries) is reasonable in patients with 1 or more of the following.212-220 (Level of Evidence: B): a. Limitations to traditional CABG, such as heavily calcied proximal aorta or poor target vessels for CABG (but amenable to PCI); b. Lack of suitable graft conduits; c. Unfavorable LAD artery for PCI (ie, excessive vessel tortuosity or chronic total occlusion).

3.3. Revascularization to Improve Symptoms Class I


1. CABG or PCI to improve symptoms is benecial in patients with 1 or more signicant (70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite GDMT.176,193-202 (Level of Evidence: A)

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Class IIb
1. Hybrid coronary revascularization (dened as the planned combination of LIMA-to-LAD artery grafting and PCI of 1 non-LAD coronary arteries) may be reasonable as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk-benet ratio of the procedures. (Level of Evidence: C)

Class IIa
1. In patients undergoing CABG, it is reasonable to treat with statin therapy to lower the low-density lipoprotein cholesterol to less than 70 mg/dL in very high-risk* patients.236-238,247a,248-250 (Level of Evidence: C) 2. For patients undergoing urgent or emergency CABG who are not taking a statin, it is reasonable to initiate high-dose statin therapy immediately.250a (Level of Evidence: C)

4. PERIOPERATIVE MANAGEMENT: RECOMMENDATIONS 4.1. Preoperative Antiplatelet Therapy Class I


1. Aspirin (100 mg to 325 mg daily) should be administered to CABG patients preoperatively.221-223 (Level of Evidence: B) 2. In patients referred for elective CABG, clopidogrel and ticagrelor should be discontinued for at least 5 days before surgery224-226 (Level of Evidence: B) and prasugrel for at least 7 days (Level of Evidence: C) to limit blood transfusions. 3. In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding complications.225,227-229 (Level of Evidence: B) 4. In patients referred for CABG, short-acting intravenous glycoprotein IIb/IIIa inhibitors (eptibatide or tiroban) should be discontinued for at least 2 to 4 hours before surgery230,231 and abciximab for at least 12 hours beforehand232 to limit blood loss and transfusions. (Level of Evidence: B)

Class III: Harm


1. Discontinuation of statin or other dyslipidemic therapy is not recommended before or after CABG in patients without adverse reactions to therapy.251-253 (Level of Evidence: B)

4.4. Hormonal Manipulation Class I


1. Use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection, after CABG.254-256 (Level of Evidence: B)

Class IIb
1. The use of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration less than 140 mg/dL has uncertain effectiveness.257-259 (Level of Evidence: B)

Class IIb
1. In patients referred for urgent CABG, it may be reasonable to perform surgery less than 5 days after clopidogrel or ticagrelor has been discontinued and less than 7 days after prasugrel has been discontinued. (Level of Evidence: C)

Class III: Harm


1. Postmenopausal hormonal therapy (estrogen/prosgesterone) should not be administered to women undergoing CABG.260-262 (Level of Evidence: B)

4.2. Postoperative Antiplatelet Therapy Class I


1. If aspirin (100 mg to 325 mg daily) was not initiated preoperatively, it should be initiated within 6 hours postoperatively and then continued indenitely to reduce the occurrence of saphenous vein graft closure and adverse cardiovascular events.223,233,234 (Level of Evidence: A)

4.5. Perioperative Beta Blockers Class I


1. Beta blockers should be administered for at least 24 hours before CABG to all patients without contraindications to reduce the incidence or clinical sequelae of postoperative AF.263-267,267a-267c (Level of Evidence: B) 2. Beta blockers should be reinstituted as soon as possible after CABG in all patients without contraindications to reduce the incidence or clinical sequelae of AF.263-267,267a-267c (Level of Evidence: B) 3. Beta blockers should be prescribed to all CABG patients without contraindications at the time of hospital discharge. (Level of Evidence: C)

Class IIa
1. For patients undergoing coronary artery bypass grafting, clopidogrel 75 mg daily is a reasonable alternative in patients who are intolerant of or allergic to aspirin. (Level of Evidence: C)

Class IIa 4.3. Management of Hyperlipidemia Class I


1. All patients undergoing CABG should receive statin therapy, unless contraindicated.235-247,247a (Level of Evidence: A) 2. In patients undergoing CABG, an adequate dose of statin should be used to reduce low-density lipoprotein cholesterol to less than 100 mg/dL and to achieve at least a 30% lowering of low-density lipoprotein cholesterol.235-239,247a (Level of Evidence: C) 1. Preoperative use of beta blockers in patients without contraindications, particularly in those with an LV ejection fraction (LVEF)

* Presence of established cardiovascular disease plus (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors of the metabolic syndrome (especially high triglycerides 200 mg/dL plus non-high-density lipoprotein cholesterol 130 mg/dL with low high-density lipoprotein cholesterol [<40 mg/dL]), and (4) acute coronary syndromes.

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greater than 30%, can be effective in reducing the risk of inhospital mortality.268-270 (Level of Evidence: B) 2. Beta blockers can be effective in reducing the incidence of perioperative myocardial ischemia.271-274 (Level of Evidence: B) 3. Intravenous administration of beta blockers in clinically stable patients unable to take oral medications is reasonable in the early postoperative period.275 (Level of Evidence: B)

4.8. Emotional Dysfunction and Psychosocial Considerations Class IIa


1. Cognitive behavior therapy or collaborative care for patients with clinical depression after CABG can be benecial to reduce objective measures of depression.294-298 (Level of Evidence: B)

Class IIb
1. The effectiveness of preoperative beta blockers in reducing inhospital mortality rate in patients with LVEF less than 30% is uncertain.268,276 (Level of Evidence: B)

4.9. Cardiac Rehabilitation Class I


1. Cardiac rehabilitation is recommended for all eligible patients after CABG.299-301,301a-301d (Level of Evidence: A)

4.6. Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers Class I


1. Angiotensin-converting enzyme (ACE) inhibitors and angiotensinreceptor blockers given before CABG should be reinstituted postoperatively once the patient is stable, unless contraindicated.277-279 (Level of Evidence: B) 2. ACE inhibitors or angiotensin-receptor blockers should be initiated postoperatively and continued indenitely in CABG patients who were not receiving them preoperatively, who are stable, and who have an LVEF less than or equal to 40%, hypertension, diabetes mellitus, or chronic kidney disease, unless contraindicated.278,279a,279b (Level of Evidence: A)

4.10. Perioperative Monitoring 4.10.1. Electrocardiographic Monitoring Class I


1. Continuous monitoring of the electrocardiogram for arrhythmias should be performed for at least 48 hours in all patients after CABG.265,302,303 (Level of Evidence: B)

Class IIa
1. Continuous ST-segment monitoring for detection of ischemia is reasonable in the intraoperative period for patients undergoing CABG.56,304-306 (Level of Evidence: B)

Class IIa
1. It is reasonable to initiate ACE inhibitors or angiotensin-receptor blockers postoperatively and to continue them indenitely in all CABG patients who were not receiving them preoperatively and are considered to be at low risk (ie, those with a normal LVEF in whom cardiovascular risk factors are well controlled), unless contraindicated.278-282 (Level of Evidence: B)

Class IIb
1. Continuous ST-segment monitoring for detection of ischemia may be considered in the early postoperative period after CABG.272,302,307-310 (Level of Evidence: B)

4.10.2. Pulmonary Artery Catheterization Class I


1. Placement of a pulmonary artery catheter is indicated, preferably before the induction of anesthesia or surgical incision, in patients in cardiogenic shock undergoing CABG. (Level of Evidence: C)

Class IIb
1. The safety of the preoperative administration of ACE inhibitors or angiotensin-receptor blockers in patients on chronic therapy is uncertain.283-288 (Level of Evidence: B) 2. The safety of initiating ACE inhibitors or angiotensin-receptor blockers before hospital discharge is not well established.278,280,282,289 (Level of Evidence: B)

Class IIa
1. Placement of a pulmonary artery catheter can be useful in the intraoperative or early postoperative period in patients with acute hemodynamic instability.311-316 (Level of Evidence: B)

4.7. Smoking Cessation Class I


1. All smokers should receive in-hospital educational counseling and be offered smoking cessation therapy during CABG hospitalization.291-293,293a (Level of Evidence: A)

Class IIb
1. Placement of a pulmonary artery catheter may be reasonable in clinically stable patients undergoing CABG after consideration of baseline patient risk, the planned surgical procedure, and the practice setting.311-316 (Level of Evidence: B)

Class IIb
1. The effectiveness of pharmacological therapy for smoking cessation offered to patients before hospital discharge is uncertain. (Level of Evidence: C)

4.10.3. Central Nervous System Monitoring Class IIb


1. The effectiveness of intraoperative monitoring of the processed electroencephalogram to reduce the possibility of adverse recall of

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clinical events or for detection of cerebral hypoperfusion in CABG patients is uncertain.449-451 (Level of Evidence: B) 2. The effectiveness of routine use of intraoperative or early postoperative monitoring of cerebral oxygen saturation via near-infrared spectroscopy to detect cerebral hypoperfusion in patients undergoing CABG is uncertain.317-319 (Level of Evidence: B)

5. CABG-ASSOCIATED MORBIDITY AND MORTALITY: OCCURRENCE AND PREVENTION: RECOMMENDATIONS 5.1. Public Reporting of Cardiac Surgery Outcomes Class I
1. Public reporting of cardiac surgery outcomes should use riskadjusted results based on clinical data.320-327 (Level of Evidence: B)

left main coronary stenosis, peripheral artery disease, history of cerebrovascular disease [transient ischemic attack, stroke, etc.], hypertension, smoking, and diabetes mellitus).346,347 (Level of Evidence: C) 2. In the CABG patient with a previous transient ischemic attack or stroke and a signicant (50% to 99%) carotid artery stenosis, it is reasonable to consider carotid revascularization in conjunction with CABG. In such an individual, the sequence and timing (simultaneous or staged) of carotid intervention and CABG should be determined by the patients relative magnitudes of cerebral and myocardial dysfunction. (Level of Evidence: C)

Class IIb
1. In the patient scheduled to undergo CABG who has no history of transient ischemic attack or stroke, carotid revascularization may be considered in the presence of bilateral severe (70% to 99%) carotid stenoses or a unilateral severe carotid stenosis with a contralateral occlusion. (Level of Evidence: C)

5.1.1. Use of Outcomes or Volume as CABG Quality Measures Class I


1. All cardiac surgery programs should participate in a state, regional, or national clinical data registry and should receive periodic reports of their risk-adjusted outcomes. (Level of Evidence: C)

5.4. Mediastinitis/Perioperative Infection Class I


1. Preoperative antibiotics should be administered to all patients to reduce the risk of postoperative infection.348-353 (Level of Evidence: A) 2. A rst- or second-generation cephalosporin is recommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus colonization.353-361 (Level of Evidence: A) 3. Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected methicillin-resistant S. aureus colonization.356,362-364 (Level of Evidence: B) 4. A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances. Primary or secondary closure with muscle or omental ap is recommended.365-367 Vacuum therapy in conjunction with early and aggressive debridement is an effective adjunctive therapy.368-377 (Level of Evidence: B) 5. Use of a continuous intravenous insulin protocol to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the risk of deep sternal wound infection.256,259,378-381 (Level of Evidence: B)

Class IIa
1. When credible risk-adjusted outcomes data are not available, volume can be useful as a structural metric of CABG quality.328-342 (Level of Evidence: B)

Class IIb
1. Afliation with a high-volume tertiary center might be considered by cardiac surgery programs that perform fewer than 125 CABG procedures annually. (Level of Evidence: C)

5.2. Use of Epiaortic Ultrasound Imaging to Reduce Stroke Rates Class IIa
1. Routine epiaortic ultrasound scanning is reasonable to evaluate the presence, location, and severity of plaque in the ascending aorta to reduce the incidence of atheroembolic complications.343-345 (Level of Evidence: B)

Class IIa
1. When blood transfusions are needed, leukocyte-ltered blood can be useful to reduce the rate of overall perioperative infection and in-hospital death.382-385 (Level of Evidence: B) 2. The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.386,387 (Level of Evidence: A) 3. The routine use of intranasal mupirocin is reasonable in patients who are not carriers of S. aureus, unless an allergy exists. (Level of Evidence: C)

5.3. The Role of Preoperative Carotid Artery Noninvasive Screening in CABG Patients Class I
1. A multidisciplinary team approach (consisting of a cardiologist, cardiac surgeon, vascular surgeon, and neurologist) is recommended for patients with clinically signicant carotid artery disease for whom CABG is planned. (Level of Evidence: C)

Class IIb
1. The use of bilateral internal mammary arteries in patients with diabetes mellitus is associated with an increased risk of deep sternal wound infection, but it may be reasonable when the overall benet to the patient outweighs this increased risk. (Level of Evidence: C)

Class IIa
1. Carotid artery duplex scanning is reasonable in selected patients who are considered to have high-risk features (ie, age >65 years,

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5.5. Renal Dysfunction Class IIb


1. In patients with preoperative renal dysfunction (creatinine clearance <60 mL/min), off-pump CABG may be reasonable to reduce the risk of acute kidney injury.388-392 (Level of Evidence: B) 2. In patients with preexisting renal dysfunction undergoing onpump CABG, maintenance of a perioperative hematocrit greater than 19% and mean arterial pressure greater than 60 mm Hg may be reasonable. (Level of Evidence: C) 3. In patients with preexisting renal dysfunction, a delay of surgery after coronary angiography may be reasonable until the effect of radiographic contrast material on renal function is assessed.393-395 (Level of Evidence: B) 4. The effectiveness of pharmacological agents to provide renal protection during cardiac surgery is uncertain.396-418 (Level of Evidence: B)

5.8. Perioperative Bleeding/Transfusion Class I


1. Lysine analogues are useful intraoperatively and postoperatively in patients undergoing on-pump CABG to reduce perioperative blood loss and transfusion requirements.431-438 (Level of Evidence: A) 2. A multimodal approach with transfusion algorithms, point-of-care testing, and a focused blood conservation strategy should be used to limit the number of transfusions.439-444 (Level of Evidence: A) 3. In patients taking thienopyridines (clopidogrel or prasugrel) or ticagrelor in whom elective CABG is planned, clopidogrel and ticagrelor should be withheld for at least 5 days224,225,227,228,445-451 (Level of Evidence: B) and prasugrel for at least 7 days 452 (Level of Evidence: C) before surgery. 4. It is recommended that surgery be delayed after the administration of streptokinase, urokinase, and tissue-type plasminogen activators until hemostatic capacity is restored, if possible. The timing of recommended delay should be guided by the pharmacodynamic half-life of the involved agent. (Level of Evidence: C) 5. Tiroban or eptibatide should be discontinued at least 2 to 4 hours before CABG and abciximab at least 12 hours before CABG.230-232,436,437,453-457 (Level of Evidence: B)

5.6. Perioperative Myocardial Dysfunction Class IIa


1. In the absence of severe, symptomatic aorto-iliac occlusive disease or peripheral artery disease, the insertion of an intra-aortic balloon is reasonable to reduce mortality rate in CABG patients who are considered to be at high risk (eg, those who are undergoing reoperation or have LVEF <30% or left main CAD).419-424 (Level of Evidence: B) 2. Measurement of biomarkers of myonecrosis (eg, creatine kinaseMB, troponin) is reasonable in the rst 24 hours after CABG.425 (Level of Evidence: B)

Class IIa
1. It is reasonable to consider off-pump CABG to reduce perioperative bleeding and allogeneic blood transfusion.458-464 (Level of Evidence: A)

6. SPECIFIC PATIENT SUBSETS: RECOMMENDATIONS 6.1. Anomalous Coronary Arteries Class I


1. Coronary revascularization should be performed in patients with: a. A left main coronary artery that arises anomalously and then courses between the aorta and pulmonary artery.465-467 (Level of Evidence: B) b. A right coronary artery that arises anomalously and then courses between the aorta and pulmonary artery with evidence of myocardial ischemia.465-468 (Level of Evidence: B)

5.6.1. Transfusion Class I


1. Aggressive attempts at blood conservation are indicated to limit hemodilutional anemia and the need for intraoperative and perioperative allogeneic red blood cell transfusion in CABG patients.426-429 (Level of Evidence: B)

5.7. Perioperative Dysrhythmias Class I


1. Beta blockers should be administered for at least 24 hours before CABG to all patients without contraindications to reduce the incidence or clinical sequelae of postoperative AF.263-267,267a-267c (Level of Evidence: B) 2. Beta blockers should be reinstituted as soon as possible after CABGin all patients without contraindications to reduce the incidence or clinical sequelae of AF.263-267,267a-267c (Level of Evidence: B)

Class IIb
1. Coronary revascularization may be reasonable in patients with a LAD coronary artery that arises anomalously and then courses between the aorta and pulmonary artery. (Level of Evidence: C)

Class IIa
1. Preoperative administration of amiodarone to reduce the incidence of postoperative AF is reasonable for patients at high risk for postoperative AF who have contraindications to beta blockers.430 (Level of Evidence: B) 2. Digoxin and nondihydropyridine calcium channel blockers can be useful to control the ventricular rate in the setting of AF but are not indicated for prophylaxis.265 (Level of Evidence: B)

6.2. Patients With Chronic Obstructive Pulmonary Disease/Respiratory Insufciency Class IIa
1. Preoperative intensive inspiratory muscle training is reasonable to reduce the incidence of pulmonary complications in patients at high risk for respiratory complications after CABG.469 (Level of Evidence: B)

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Class IIb
1. After CABG, noninvasive positive pressure ventilation may be reasonable to improve pulmonary mechanics and to reduce the need for reintubation.470,471 (Level of Evidence: B) 2. High thoracic epidural analgesia may be considered to improve lung function after CABG.472,473 (Level of Evidence: B

GDMT has failed and the coronary stenoses are not amenable to PCI.186,486 (Level of Evidence: B)

STAFF American College of Cardiology Foundation David R. Holmes, Jr, MD, FACC, President John C. Lewin, MD, Chief Executive Ofcer Janet Wright, MD, FACC, Senior Vice President, Science and Quality Charlene May, Senior Director, Science and Clinical Policy Erin A. Barrett, MPS, Senior Specialist, Science and Clinical Policy American College of Cardiology Foundation/ American Heart Association Lisa Bradeld, CAE, Director, Science and Clinical Policy Debjani Mukherjee, MPH, Associate Director, EvidenceBased Medicine Sue Keller, BSN, MPH, Senior Specialist, Evidence-Based Medicine Maria Koinis, Specialist, Science and Clinical Policy Jesse M. Welsh, Specialist, Science and Clinical Policy American Heart Association Ralph L. Sacco, MS, MD, FAAN, FAHA, President Nancy Brown, Chief Executive Ofcer Rose Marie Robertson, MD, FAHA, Chief Science Ofcer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Ofce of Science Operations Cheryl L. Perkins, MD, RPh, Science and Medicine Advisor, Ofce of Science Operations References
1. ACCF/AHA Task Force on Practice Guidelines. Methodologies and Policies from the ACCF/AHA Task Force on Practice Guidelines. Available at; http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_ Writing_Committees.pdf. http://circ.ahajournals.org/site/manual/index.xhtml. Accessed July 1, 2011. 2. Institute of Medicine. Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: The National Academies Press; 2011. 3. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. 4. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011. published online before print November 7, 2011, doi:10.1016/j.jacc.2011.08.009. Accessed November 7, 2011. 5. Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients. Cochrane Database Syst Rev. 2003;CD003587-10.1002/ 14651858.CD003587. 6. Myles PS, Daly DJ, Djaiani G, et al. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology. 2003;99:982-7. 7. van Mastrigt GA, Maessen JG, Heijmans J, et al. Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials. Crit Care Med. 2006;34:1624-34.

6.3. Patients With End-Stage Renal Disease on Dialysis Class IIb


1. CABG to improve survival rate may be reasonable in patients with end-stage renal disease undergoing CABG for left main coronary artery stenosis of greater than or equal to 50%.474 (Level of Evidence: C) 2. CABG to improve survival rate or to relieve angina despite GDMT may be reasonable for patients with end-stage renal disease with signicant stenoses (70%) in 3 major vessels or in the proximal LAD artery plus 1 other major vessel, regardless of LV systolic function.475 (Level of Evidence: B)

Class III: Harm


1. CABG should not be performed in patients with end-stage renal disease whose life expectancy is limited by noncardiac issues. (Level of Evidence: C)

6.4. Patients With Concomitant Valvular Disease Class I


1. Patients undergoing CABG who have at least moderate aortic stenosis should have concomitant aortic valve replacement.476-479 (Level of Evidence: B) 2. Patients undergoing CABG who have severe ischemic mitral valve regurgitation not likely to resolve with revascularization should have concomitant mitral valve repair or replacement at the time of CABG.480-485 (Level of Evidence: B)

Class IIa
1. In patients undergoing CABG who have moderate ischemic mitral valve regurgitation not likely to resolve with revascularization, concomitant mitral valve repair or replacement at the time of CABG is reasonable.480-485 (Level of Evidence: B)

Class IIb
1. Patients undergoing CABG who have mild aortic stenosis may be considered for concomitant aortic valve replacement when evidence (eg, moderate-severe leaet calcication) suggests that progression of the aortic stenosis may be rapid and the risk of the combined procedure is acceptable. (Level of Evidence: C)

6.5. Patients With Previous Cardiac Surgery Class IIa


1. In patients with a patent LIMA to the LAD artery and ischemia in the distribution of the right or left circumex coronary arteries, it is reasonable to recommend reoperative CABG to treat angina if

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161. Tsuyuki RT, Shrive FM, Galbraith PD, et al. Revascularization in patients with heart failure. CMAJ. 2006;175:361-5. 162. Deleted in proof. 163. Deleted in proof. 164. Brener SJ, Lytle BW, Casserly IP, et al. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004;109:2290-5. 165. Hannan EL, Racz MJ, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005;352:2174-83. 166. Deleted in proof. 167. Deleted in proof. 168. The BARI Investigators. Inuence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997;96:1761-9. 169. The BARI Investigators. The nal 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol. 2007;49:1600-6. 170. Banning AP, Westaby S, Morice MC, et al. Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents. J Am Coll Cardiol. 2010;55: 1067-75. 171. Hoffman SN, TenBrook JA, Wolf MP, et al. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol. 2003;41:1293-304. 172. Hueb W, Lopes NH, Gersh BJ, et al. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2007;115:1082-9. 173. Malenka DJ, Leavitt BJ, Hearne MJ, et al. Comparing long-term survival of patients with multivessel coronary disease after CABG or PCI: analysis of BARIlike patients in northern New England. Circulation. 2005;112:I371-6. 174. Niles NW, McGrath PD, Malenka D, et al. Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001;37: 1008-15. 175. Weintraub WS, Stein B, Kosinski A, et al. Outcome of coronary bypass surgery versus coronary angioplasty in diabetic patients with multivessel coronary artery disease. J Am Coll Cardiol. 1998;31:10-9. 176. Boden WE, ORourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503-16. 177. Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med. 2011;364:1617-25. 178. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction. N Engl J Med. 2011;364:1607-16. 179. Brener SJ, Lytle BW, Casserly IP, et al. Predictors of revascularization method and long-term outcome of percutaneous coronary intervention or repeat coronary bypass surgery in patients with multivessel coronary disease and previous coronary bypass surgery. Eur Heart J. 2006;27:413-8. 180. Gurnkel EP, Perez dlH, Brito VM, et al. Invasive vs non-invasive treatment in acute coronary syndromes and prior bypass surgery. Int J Cardiol. 2007;119: 65-72. 181. Lytle BW, Loop FD, Taylor PC, et al. The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries. J Thorac Cardiovasc Surg. 1993;105:605-12. 182. Morrison DA, Sethi G, Sacks J, et al. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial: Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol. 2001;38:143-9. 183. Pfautsch P, Frantz E, Ellmer A, et al. [Long-term outcome of therapy of recurrent myocardial ischemia after surgical revascularization]. Z Kardiol. 1999;88: 489-97. 184. Sergeant P, Blackstone E, Meyns B, et al. First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting. Eur J Cardiothorac Surg. 1998;14:480-7. 185. Stephan WJ, OKeefe JH Jr, Piehler JM, et al. Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery. J Am Coll Cardiol. 1996;28:1140-6.

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186. Subramanian S, Sabik JF III, Houghtaling PL, et al. Decision-making for patients with patent left internal thoracic artery grafts to left anterior descending. Ann Thorac Surg. 2009;87:1392-8. 187. Weintraub WS, Jones EL, Morris DC, et al. Outcome of reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery. Circulation. 1997;95:868-77. 188. Shaw LJ, Berman DS, Maron DJ, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117:1283-91. 189. Cashin WL, Sanmarco ME, Nessim SA, et al. Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed. N Engl J Med. 1984;311:824-8. 190. Pijls NH, De Bruyne B, Peels K, et al. Measurement of fractional ow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med. 1996; 334:1703-8. 191. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional ow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360: 213-24. 192. Sawada S, Bapat A, Vaz D, et al. Incremental value of myocardial viability for prediction of long-term prognosis in surgically revascularized patients with left ventricular dysfunction. J Am Coll Cardiol. 2003;42:2099-105. 193. TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME); a randomised trial. Lancet. 2001;358:951-7. 194. Benzer W, Hofer S, Oldridge NB. Health-related quality of life in patients with coronary artery disease after different treatments for angina in routine clinical practice. Herz. 2003;28:421-8. 195. Bonaros N, Schachner T, Ohlinger A, et al. Assessment of health-related quality of life after coronary revascularization. Heart Surg Forum. 2005;8:E380-5. 196. Bucher HC, Hengstler P, Schindler C, et al. Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials. BMJ. 2000;321:73-7. 197. Favarato ME, Hueb W, Boden WE, et al. Quality of life in patients with symptomatic multivessel coronary artery disease: a comparative post hoc analyses of medical, angioplasty or surgical strategies-MASS II trial. Int J Cardiol. 2007; 116:364-70. 198. Hueb W, Lopes N, Gersh BJ, et al. Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2010;122:949-57. 199. Pocock SJ, Henderson RA, Seed P, et al. Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery: 3-year followup in the Randomized Intervention Treatment of Angina (RITA) Trial. Circulation. 1996;94:135-42. 200. Pocock SJ, Henderson RA, Clayton T, et al. Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial: Randomized Intervention Treatment of Angina. J Am Coll Cardiol. 2000;35:907-14. 201. Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359:677-87. 202. Wijeysundera HC, Nallamothu BK, Krumholz HM, et al. Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med. 2010;152:370-9. 203. Schoeld PM, Sharples LD, Caine N, et al. Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial [published correction appears in Lancet. 1999;353:1714]. Lancet. 1999;353:519-24. 204. Aaberge L, Nordstrand K, Dragsund M, et al. Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris: Clinical results from the Norwegian randomized trial. J Am Coll Cardiol. 2000;35: 1170-7. 205. Burkhoff D, Schmidt S, Schulman SP, et al. Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial: ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison. Lancet. 1999;354: 885-90. 206. Allen KB, Dowling RD, DelRossi AJ, et al. Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial. J Thorac Cardiovasc Surg. 2000;119: 540-9.

207. Stamou SC, Boyce SW, Cooke RH, et al. One-year outcome after combined coronary artery bypass grafting and transmyocardial laser revascularization for refractory angina pectoris. Am J Cardiol. 2002;89:1365-8. 208. Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007;115:813-8. 209. Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting: Stent Anticoagulation Restenosis Study Investigators. N Engl J Med. 1998;339:1665-71. 210. Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007;356:1020-9. 211. McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004;364:1519-21. 212. Bonatti J, Schachner T, Bonaros N, et al. Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session: The COMBINATION pilot study. Cardiology. 2008;110:92-5. 213. Gilard M, Bezon E, Cornily JC, et al. Same-day combined percutaneous coronary intervention and coronary artery surgery. Cardiology. 2007;108:363-7. 214. Holzhey DM, Jacobs S, Mochalski M, et al. Minimally invasive hybrid coronary artery revascularization. Ann Thorac Surg. 2008;86:1856-60. 215. Kon ZN, Brown EN, Tran R, et al. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. J Thorac Cardiovasc Surg. 2008;135:367-75. 216. Reicher B, Poston RS, Mehra MR, et al. Simultaneous hybrid percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes. Am Heart J. 2008;155:661-7. 217. Vassiliades TA Jr, Douglas JS, Morris DC, et al. Integrated coronary revascularization with drug-eluting stents: immediate and seven-month outcome. J Thorac Cardiovasc Surg. 2006;131:956-62. 218. Zhao DX, Leacche M, Balaguer JM, et al. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room. J Am Coll Cardiol. 2009;53:232-41. 219. Angelini GD, Wilde P, Salerno TA, et al. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisation. Lancet. 1996;347: 757-8. 220. Simoons ML. Myocardial revascularization-bypass surgery or angioplasty? N Engl J Med. 1996;335:275-7. 221. Bybee KA, Powell BD, Valeti U, et al. Preoperative aspirin therapy is associated with improved postoperative outcomes in patients undergoing coronary artery bypass grafting. Circulation. 2005;112:I286-92. 222. Dacey LJ, Munoz JJ, Johnson ER, et al. Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients. Ann Thorac Surg. 2000; 70:1986-90. 223. Mangano DT, Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002; 347:1309-17. 224. Berger JS, Frye CB, Harshaw Q, et al. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol. 2008;52:1693-701. 225. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol. 2010;57:672-84. 226. Hongo RH, Ley J, Dick SE, et al. The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting. J Am Coll Cardiol. 2002;40:231-7. 227. Firanescu CE, Martens EJ, Schonberger JP, et al. Postoperative blood loss in patients undergoing coronary artery bypass surgery after preoperative treatment with clopidogrel: A prospective randomised controlled study. Eur J Cardiothorac Surg. 2009;36:856-62. 228. Herman CR, Buth KJ, Kent BA, et al. Clopidogrel increases blood transfusion and hemorrhagic complications in patients undergoing cardiac surgery. Ann Thorac Surg. 2010;89:397-402. 229. Mehta RH, Sheng S, OBrien SM, et al. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: incidence, risk factors, time trends, and outcomes. Circ Cardiovasc Qual Outcomes. 2009;2:583-90.

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354. Bolon MK, Morlote M, Weber SG, et al. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis. 2004;38:1357-63. 355. Finkelstein R, Rabino G, Mashiah T, et al. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thorac Cardiovasc Surg. 2002;123:326-32. 356. Maki DG, Bohn MJ, Stolz SM, et al. Comparative study of cefazolin, cefamandole, and vancomycin for surgical prophylaxis in cardiac and vascular operations: A double-blind randomized trial. J Thorac Cardiovasc Surg. 1992;104:1423-34. 357. Saginur R, Croteau D, Bergeron MG. Comparative efcacy of teicoplanin and cefazolin for cardiac operation prophylaxis in 3027 patients: The ESPRIT Group. J Thorac Cardiovasc Surg. 2000;120:1120-30. 358. Salminen US, Viljanen TU, Valtonen VV, et al. Ceftriaxone versus vancomycin prophylaxis in cardiovascular surgery. J Antimicrob Chemother. 1999;44:287-90. 359. Townsend TR, Reitz BA, Bilker WB, et al. Clinical trial of cefamandole, cefazolin, and cefuroxime for antibiotic prophylaxis in cardiac operations. J Thorac Cardiovasc Surg. 1993;106:664-70. 360. Vuorisalo S, Pokela R, Syrjala H. Comparison of vancomycin and cefuroxime for infection prophylaxis in coronary artery bypass surgery. Infect Control Hosp Epidemiol. 1998;19:234-9. 361. Wilson AP, Treasure T, Gruneberg RN, et al. Antibiotic prophylaxis in cardiac surgery: a prospective comparison of two dosage regimens of teicoplanin with a combination of ucloxacillin and tobramycin. J Antimicrob Chemother. 1988; 21:213-23. 362. Centers for Diseases Control and Prevention. Recommendations for preventing the spread of vancomycin resistance: Recommendations of the Hospital Infection Control Practices Advisory Committee. MMWR Morb Mortal Wkly Rep. 2010;44:1-13. 363. Spelman D, Harrington G, Russo P, et al. Clinical, microbiological, and economic benet of a change in antibiotic prophylaxis for cardiac surgery. Infect Control Hosp Epidemiol. 2002;23:402-4. 364. Walsh EE, Greene L, Kirshner R. Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery. Arch Intern Med. 2010;171:68-73. 365. Jurkiewicz MJ, Bostwick J III, Hester TR, et al. Infected median sternotomy wound: Successful treatment by muscle aps. Ann Surg. 1980;191:738-44. 366. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle aps for sternal wound infection. Ann Thorac Surg. 1998;65:1046-9. 367. Wong CH, Senewiratne S, Garlick B, et al. Two-stage management of sternal wound infection using bilateral pectoralis major advancement ap. Eur J Cardiothorac Surg. 2006;30:148-52. 368. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563-76. 369. Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies. Eur J Cardiothorac Surg. 2010;37:880-7. 370. Cowan KN, Teague L, Sue SC, et al. Vacuum-assisted wound closure of deep sternal infections in high-risk patients after cardiac surgery. Ann Thorac Surg. 2005;80:2205-12. 371. Doss M, Martens S, Wood JP, et al. Vacuum-assisted suction drainage versus conventional treatment in the management of poststernotomy osteomyelitis. Eur J Cardiothorac Surg. 2002;22:934-8. 372. Ennker IC, Malkoc A, Pietrowski D, et al. The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis: a single center experience with 54 patients. J Cardiothorac Surg. 2009;4:5. 373. Fleck T, Moidl R, Giovanoli P, et al. A conclusion from the rst 125 patients treated with the vacuum assisted closure system for postoperative sternal wound infection. Interact Cardiovasc Thorac Surg. 2006;5:145-8. 374. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg. 2002;74:1596-600. 375. Luckraz H, Murphy F, Bryant S, et al. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg. 2003;125:301-5. 376. Sjogren J, Gustafsson R, Nilsson J, et al. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg. 2005;79:2049-55. 377. Sjogren J, Nilsson J, Gustafsson R, et al. The impact of vacuum-assisted closure on long-term survival after post-sternotomy mediastinitis. Ann Thorac Surg. 2005;80:1270-5.

378. Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130:1144. 379. Furnary AP, Wu Y. Eliminating the diabetic disadvantage: the Portland Diabetic Project. Semin Thorac Cardiovasc Surg. 2006;18:302-8. 380. Kirdemir P, Yildirim V, Kiris I, et al. Does continuous insulin therapy reduce postoperative supraventricular tachycardia incidence after coronary artery bypass operations in diabetic patients? J Cardiothorac Vasc Anesth. 2008;22:383-7. 381. Ouattara A, Lecomte P, Le Manach Y, et al. Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. Anesthesiology. 2005;103:687-94. 382. Bilgin YM, van de Watering LM, Eijsman L, et al. Double-blind, randomized controlled trial on the effect of leukocyte-depleted erythrocyte transfusions in cardiac valve surgery. Circulation. 2004;109:2755-60. 383. Blumberg N, Heal JM, Cowles JW, et al. Leukocyte-reduced transfusions in cardiac surgery results of an implementation trial. Am J Clin Pathol. 2002;118: 376-81. 384. Romano G, Mastroianni C, Bancone C, et al. Leukoreduction program for red blood cell transfusions in coronary surgery: association with reduced acute kidney injury and in-hospital mortality. J Thorac Cardiovasc Surg. 2010;140:188-95. 385. van de Watering LM, Hermans J, Houbiers JG, et al. Benecial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery: a randomized clinical trial. Circulation. 1998;97: 562-8. 386. Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64: 162-8. 387. van Rijen M, Bonten M, Wenzel R, et al. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;CD006216. 388. Ascione R, Nason G, Al-Ruzzeh S, et al. Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysisdependent renal insufciency. Ann Thorac Surg. 2001;72:2020-5. 389. Chukwuemeka A, Weisel A, Maganti M, et al. Renal dysfunction in high-risk patients after on-pump and off-pump coronary artery bypass surgery: a propensity score analysis. Ann Thorac Surg. 2005;80:2148-53. 390. Di Mauro M, Gagliardi M, Iaco AL, et al. Does off-pump coronary surgery reduce postoperative acute renal failure? The importance of preoperative renal function. Ann Thorac Surg. 2007;84:1496-502. 391. Nigwekar SU, Kandula P, Hix JK, et al. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized and observational studies. Am J Kidney Dis. 2009;54:413-23. 392. Sajja LR, Mannam G, Chakravarthi RM, et al. Coronary artery bypass grafting with or without cardiopulmonary bypass in patients with preoperative nondialysis dependent renal insufciency: a randomized study. J Thorac Cardiovasc Surg. 2007;133:378-88. 393. Del Duca D, Iqbal S, Rahme E, et al. Renal failure after cardiac surgery: timing of cardiac catheterization and other perioperative risk factors. Ann Thorac Surg. 2007;84:1264-71. 394. Medalion B, Cohen H, Assali A, et al. The effect of cardiac angiography timing, contrast media dose, and preoperative renal function on acute renal failure after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2010;139: 1539-44. 395. Ranucci M, Ballotta A, Kunkl A, et al. Inuence of the timing of cardiac catheterization and the amount of contrast media on acute renal failure after cardiac surgery. Am J Cardiol. 2008;101:1112-8. 396. Adabag AS, Ishani A, Bloomeld HE, et al. Efcacy of N-acetylcysteine in preventing renal injury after heart surgery: a systematic review of randomized trials. Eur Heart J. 2009;30:1910-7. 397. Amar D, Fleisher M. Diltiazem treatment does not alter renal function after thoracic surgery. Chest. 2001;119:1476-9. 398. Caimmi PP, Pagani L, Micalizzi E, et al. Fenoldopam for renal protection in patients undergoing cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2003;17:491-4. 399. Cogliati AA, Vellutini R, Nardini A, et al. Fenoldopam infusion for renal protection in high-risk cardiac surgery patients: a randomized clinical study. J Cardiothorac Vasc Anesth. 2007;21:847-50. 400. Davis RF, Giesecke NM. Hemodilution and priming solutions. In: Gravlee GP, Davis RF, Kurusz M, Utley JR, editors. Cardiopulmonary Bypass: Principles and Practice. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:186-196.

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401. El-Hamamsy I, Stevens LM, Carrier M, et al. Effect of intravenous N-acetylcysteine on outcomes after coronary artery bypass surgery: a randomized, doubleblind, placebo-controlled clinical trial. J Thorac Cardiovasc Surg. 2007;133:7-12. 402. Fansa I, Gol M, Nisanoglu V, et al. Does diltiazem inhibit the inammatory response in cardiopulmonary bypass? Med Sci Monit. 2003;9:PI30-6. 403. Fischer UM, Tossios P, Mehlhorn U. Renal protection by radical scavenging in cardiac surgery patients. Curr Med Res Opin. 2005;21:1161-4. 404. Friedrich JO, Adhikari N, Herridge MS, et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142:510-24. 405. Haase M, Haase-Fielitz A, Bagshaw SM, et al. Phase II, randomized, controlled trial of high-dose N-acetylcysteine in high-risk cardiac surgery patients. Crit Care Med. 2007;35:1324-31. 406. Ip-Yam PC, Murphy S, Baines M, et al. Renal function and proteinuria after cardiopulmonary bypass: the effects of temperature and mannitol. Anesth Analg. 1994;78:842-7. 407. Landoni G, Biondi-Zoccai GG, Tumlin JA, et al. Benecial impact of fenoldopam in critically ill patients with or at risk for acute renal failure: a metaanalysis of randomized clinical trials. Am J Kidney Dis. 2007;49:56-68. 408. Landoni G, Biondi-Zoccai GG, Marino G, et al. Fenoldopam reduces the need for renal replacement therapy and in-hospital death in cardiovascular surgery: a meta-analysis. J Cardiothorac Vasc Anesth. 2008;22:27-33. 409. Murphy MB, Murray C, Shorten GD. Fenoldopam: a selective peripheral dopamine-receptor agonist for the treatment of severe hypertension. N Engl J Med. 2001;345:1548-57. 410. Nigwekar SU, Hix JK. The role of natriuretic peptide administration in cardiovascular surgery-associated renal dysfunction: a systematic review and metaanalysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2009; 23:151-60. 411. Piper SN, Kumle B, Maleck WH, et al. Diltiazem may preserve renal tubular integrity after cardiac surgery. Can J Anaesth. 2003;50:285-92. 412. Ranucci M, Soro G, Barzaghi N, et al. Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients. Ann Thorac Surg. 2004; 78:1332-7. 413. Ranucci M, De Benedetti D, Bianchini C, et al. Effects of fenoldopam infusion in complex cardiac surgical operations: a prospective, randomized, doubleblind, placebo-controlled study. Minerva Anestesiol. 2010;76:249-59. 414. Sirivella S, Gielchinsky I, Parsonnet V. Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery. Ann Thorac Surg. 2000;69:501-6. 415. Tumlin JA, Finkel KW, Murray PT, et al. Fenoldopam mesylate in early acute tubular necrosis: a randomized, double-blind, placebo-controlled clinical trial. Am J Kidney Dis. 2005;46:26-34. 416. Vesely DL. Natriuretic peptides and acute renal failure. Am J Physiol Renal Physiol. 2003;285:F167-77. 417. Wang G, Bainbridge D, Martin J, et al. N-acetylcysteine in cardiac surgery: Do the benets outweigh the risks? A meta-analytic reappraisal. J Cardiothorac Vasc Anesth. 2010;2:268-75. 418. Young EW, Diab A, Kirsh MM. Intravenous diltiazem and acute renal failure after cardiac operations. Ann Thorac Surg. 1998;65:1316-9. 419. Christenson JT, Cohen M, Ferguson JJI, et al. Trends in intraaortic balloon counterpulsation complications and outcomes in cardiac surgery. Ann Thorac Surg. 2002;74:1086-90. 420. Christenson JT, Simonet F, Badel P, et al. Optimal timing of preoperative intraaortic balloon pump support in high-risk coronary patients. Ann Thorac Surg. 1999;68:934-9. 421. Christenson JT, Licker M, Kalangos A. The role of intra-aortic counterpulsation in high-risk OPCAB surgery: a prospective randomized study. J Card Surg. 2003;18:286-94. 422. Christenson JT, Schmuziger M, Simonet F. Effective surgical management of high-risk coronary patients using preoperative intra-aortic balloon counterpulsation therapy. Cardiovasc Surg. 2001;9:383-90. 423. Urban PM, Freedman RJ, Ohman EM, et al. In-hospital mortality associated with the use of intra-aortic balloon counterpulsation. Am J Cardiol. 2004;94:181-5. 424. Santa-Cruz RA, Cohen MG, Ohman EM. Aortic counterpulsation: a review of the hemodynamic effects and indications for use. Catheter Cardiovasc Interv. 2006;67:68-77. 425. Yau JM, Alexander JH, Haey G, et al. Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from PRoject of Ex-vivo Vein graft ENgineering via Transfection [PREVENT] IV). Am J Cardiol. 2008;102:546-51.

426. Koch CG, Li L, Duncan AI, et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg. 2006;81: 1650-7. 427. Surgenor SD, DeFoe GR, Fillinger MP, et al. Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure. Circulation. 2006;114:I43-8. 428. van Straten AH, Bekker MW, Soliman Hamad MA, et al. Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact Cardiovasc Thorac Surg. 2010;10:37-42. 429. van Straten AH, Kats S, Bekker MW, et al. Risk factors for red blood cell transfusion after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2010;24:413-7. 430. Daoud EG, Strickberger SA, Man KC, et al. Preoperative amiodarone as prophylaxis against atrial brillation after heart surgery. N Engl J Med. 1997; 337:1785-91. 431. Fergusson DA, Hebert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery [published correction appears in N Engl J Med. 2010;363:1290]. N Engl J Med. 2008;358:2319-31. 432. Greilich PE, Jessen ME, Satyanarayana N, et al. The effect of epsilonaminocaproic acid and aprotinin on brinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery: a randomized, double-blind, placebo-controlled, noninferiority trial. Anesth Analg. 2009; 109:15-24. 433. Kikura M, Levy JH, Tanaka KA, et al. A double-blind, placebo-controlled trial of epsilon-aminocaproic acid for reducing blood loss in coronary artery bypass grafting surgery. J Am Coll Surg. 2006;202:216-22. 434. Mehr-Aein A, Sadeghi M, Madani-civi M. Does tranexamic acid reduce blood loss in off-pump coronary artery bypass? Asian Cardiovasc Thorac Ann. 2007; 15:285-9. 435. Mehr-Aein A, Davoodi S, Madani-civi M. Effects of tranexamic acid and autotransfusion in coronary artery bypass. Asian Cardiovasc Thorac Ann. 2007;15:49-53. 436. Murphy GJ, Mango E, Lucchetti V, et al. A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006;132:475-80, e1-8. 437. Santos AT, Kalil RA, Bauemann C, et al. A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and brinolytic activity after primary coronary artery bypass grafting. Braz J Med Biol Res. 2006;39:63-9. 438. Taghaddomi RJ, Mirzaee A, Attar AS, et al. Tranexamic acid reduces blood loss in off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2009; 23:312-5. 439. Paone G, Spencer T, Silverman NA. Blood conservation in coronary artery surgery. Surgery. 1994;116:672-7. 440. Nuttall GA, Oliver WC, Santrach PJ, et al. Efcacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology. 2001;94:773-81. 441. Royston D, von Kier S. Reduced haemostatic factor transfusion using heparinase-modied thrombelastography during cardiopulmonary bypass. Br J Anaesth. 2001;86:575-8. 442. Avidan MS, Alcock EL, Da Fonseca J, et al. Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery. Br J Anaesth. 2004;92:178-86. 443. Despotis GJ, Grishaber JE, Goodnough LT. The effect of an intraoperative treatment algorithm on physicians transfusion practice in cardiac surgery. Transfusion. 1994;34:290-6. 444. Shore-Lesserson L, Manspeizer HE, DePerio M, et al. Thromboelastographyguided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg. 1999;88:312-9. 445. Chu MW, Wilson SR, Novick RJ, et al. Does clopidogrel increase blood loss following coronary artery bypass surgery? Ann Thorac Surg. 2004;78:1536-41. 446. Englberger L, Faeh B, Berdat PA, et al. Impact of clopidogrel in coronary artery bypass grafting. Eur J Cardiothorac Surg. 2004;26:96-101. 447. Kapetanakis EI, Medlam DA, Petro KR, et al. Effect of clopidogrel premedication in off-pump cardiac surgery: are we forfeiting the benets of reduced hemorrhagic sequelae? Circulation. 2006;113:1667-74. 448. Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J. 2008;156:886-92. 449. Maltais S, Perrault LP, Do QB. Effect of clopidogrel on bleeding and transfusions after off-pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery. Eur J Cardiothorac Surg. 2008;34:127-31.

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450. Vaccarino GN, Thierer J, Albertal M, et al. Impact of preoperative clopidogrel in off pump coronary artery bypass surgery: a propensity score analysis. J Thorac Cardiovasc Surg. 2009;137:309-13. 451. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published corrections appear in N Engl J Med. 2011;345:1506; 2011;345:1716]. N Engl J Med. 2001;345:494-502. 452. Wiviott SD, Braunwald E, McCabe CH, et al., for the TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001-15. 453. Renda G, Di Pillo R, DAlleva A, et al. Surgical bleeding after pre-operative unfractionated heparin and low molecular weight heparin for coronary bypass surgery. Haematologica. 2007;92:366-73. 454. McDonald SB, Renna M, Spitznagel EL, et al. Preoperative use of enoxaparin increases the risk of postoperative bleeding and re-exploration in cardiac surgery patients. J Cardiothorac Vasc Anesth. 2005;19:4-10. 455. Jones HU, Muhlestein JB, Jones KW, et al. Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports. Circulation. 2002; 106:I19-22. 456. Kincaid EH, Monroe ML, Saliba DL, et al. Effects of preoperative enoxaparin versus unfractionated heparin on bleeding indices in patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2003;76:124-8. 457. Medalion B, Frenkel G, Patachenko P, et al. Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2003;126:1875-9. 458. Angelini GD, Taylor FC, Reeves BC, et al. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet. 2002;359:1194-9. 459. Cheng DC, Bainbridge D, Martin JE, et al. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology. 2005;102:188-203. 460. Czerny M, Baumer H, Kilo J, et al. Complete revascularization in coronary artery bypass grafting with and without cardiopulmonary bypass. Ann Thorac Surg. 2001;71:165-9. 461. Khan NE, De Souza A, Mister R, et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004; 350:21-8. 462. Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:797-808. 463. Raja SG, Dreyfus GD. Impact of off-pump coronary artery bypass surgery on postoperative bleeding: current best available evidence. J Card Surg. 2006;21:35-41. 464. van Dijk D, Nierich AP, Jansen EW, et al. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomized study. Circulation. 2001;104:1761-6. 465. Basso C, Maron BJ, Corrado D, et al. Clinical prole of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000;35:1493-501. 466. Thomas D, Salloum J, Montalescot G, et al. Anomalous coronary arteries coursing between the aorta and pulmonary trunk: clinical indications for coronary artery bypass. Eur Heart J. 1991;12:832-4. 467. Krasuski RA, Magyar D, Hart S, et al. Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp. Circulation. 2011;123:154-62.

468. Frommelt PC, Sheridan DC, Berger S, et al. Ten-year experience with surgical unroong of anomalous aortic origin of a coronary artery from the opposite sinus with an interarterial course. J Thorac Cardiovasc Surg. 2011 Mar 23 [E-pub ahead of print]. 469. Hulzebos EH, Helders PJ, Favie NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in highrisk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296:1851-7. 470. Haeffener MP, Ferreira GM, Barreto SS, et al. Incentive spirometry with expiratory positive airway pressure reduces pulmonary complications, improves pulmonary function and 6-minute walk distance in patients undergoing coronary artery bypass graft surgery. Am Heart J. 2008;156:900e1-e8. 471. Zarbock A, Mueller E, Netzer S, et al. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest. 2009;135:1252-9. 472. Kodis T, Baraki H, Singh H, et al. The minimized extracorporeal circulation system causes less inammation and organ damage. Perfusion. 2008;23:147-51. 473. Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology. 2004;101:153-61. 474. Hemmelgarn BR, Southern D, Culleton BF, et al. Survival after coronary revascularization among patients with kidney disease. Circulation. 2004;110:1890-5. 475. Liu JY, Birkmeyer NJ, Sanders JH, et al. Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery: Northern New England Cardiovascular Disease Study Group. Circulation. 2000;102:2973-7. 476. Filsou F, Aklog L, Adams DH, et al. Management of mild to moderate aortic stenosis at the time of coronary artery bypass grafting. J Heart Valve Dis. 2002; 11(Suppl 1):S45-9. 477. Smith WT IV, Ferguson TB Jr, Ryan T, et al. Should coronary artery bypass graft surgery patients with mild or moderate aortic stenosis undergo concomitant aortic valve replacement? A decision analysis approach to the surgical dilemma. J Am Coll Cardiol. 2004;44:1241-7. 478. Pereira JJ, Balaban K, Lauer MS, et al. Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery. Am J Med. 2005; 118:735-42. 479. Gillinov AM, Garcia MJ. When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization? Curr Cardiol Rep. 2005;7:101-4. 480. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122: 1125-41. 481. Aklog L, Filsou F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation. 2001;104:I68-75. 482. Trichon BH, Glower DD, Shaw LK, et al. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation. 2003;108(Suppl 1):II103-10. 483. Fattouch K, Guccione F, Sampognaro R, et al. POINT: Efcacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg. 2009;138:278-85. 484. Fattouch K, Sampognaro R, Speziale G, et al. Impact of moderate ischemic mitral regurgitation after isolated coronary artery bypass grafting. Ann Thorac Surg. 2010;90:1187-94. 485. Zoghbi W, Sarano M. Recommendations for the evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc of Echocardiography. 2003;16:777-802. 486. Sergeant P, Blackstone E, Meyns B. Is return of angina after coronary artery bypass grafting immutable, can it be delayed, and is it important? J Thorac Cardiovasc Surg. 1998;116:440-53.

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APPENDIX 1. Author relationships with industry and other entities (relevant)2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery
Ownership/ partnership/ principal
None

Committee member
L. David Hillis (Chair)

Employer/title
University of Texas Health Science Center at San Antonio Professor and Chair of the Department of Medicine Duke University Medical Center: Private Diagnostic Clinic Professor of Surgery; Chief of Thoracic Surgery Intermountain Medical CenterAssociate Chief of Cardiology

Consultant
None

Speakers bureau
None

Personal research
None

Institutional, organizational, or other nancial benet


None None

Expert witness

Voting recusals by section numbers*


None

Peter K. Smith (Vice Chair)

 Eli Lilly  Baxter BioSurgery

None

None

None

None

None

2.2.3 4.1 4.2 5.2.6

Jeffrey L. Anderson

 BMS/sanoaventis

None

None

 Toshibaz  Gilead Pharma  AstraZeneca

None

None

John A. Bittl

Charles R. Bridges

Ocala Heart Institute Munroe Regional Medical Center Interventional Cardiologist University of Pennsylvania Medical CenterChief of Cardiothoracic Surgery

None

None

None

None

None

None

2.1.6 2.2.3 4.1 4.2 4.3 5.2.6 None

 Baxter BioSurgeryz  Zymogenetics

 Bayer Pharmaceuticals

None

None

None

John G. Byrne

Joaquin E. Cigarroa

Vanderbilt University Medical Center: Division of Cardiac SurgeryChairman of Cardiac Surgery Oregon Health and Science University Associate Professor of Medicine

None

None

None

None

None

 Plaintiff, alleged mitral valve dysfunction, 2009  Defendant, retinal artery occlusion (stroke) after CABG, 2009  Defendant, timely insertion of IABP after CABG, 2009  Defendant, timely transport after acute aortic dissection, 2009  Plaintiff, unexpected intra-abdominal hemorrhage and death after AVR, 2009 None

2.2.3 4.1 4.2 5.2.6

None

None

None

None

None

None

None

None

(Continued)

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APPENDIX 1. Continued
Ownership/ partnership/ principal
None

Committee member
Verdi J. DiSesa

Employer/title
John Hopkins Hospital, Division of Cardiac SurgeryClinical Associate Cardiac, Vascular and Thoracic Surgeons, Inc.Medical Director of Cardiac Surgery Massachusetts General HospitalProfessor of Medicine UT Southwestern Medical CenterProfessor of Cardiothoracic Surgery University of Virginia Associate Professor of Internal Medicine University of ConnecticutProfessor and Chief of Cardiothoracic Surgery University of Texas Health Science Center at San Antonio Professor of Medicine University of California San Francisco, Veterans Affairs Medical CenterProfessor of Clinical Anesthesia The Heart Hospital Baylor PlanoCardiovascular Surgery, Medical Director Duke University Medical CenterAssociate Professor of Medicine Emory University/Emory HealthcareChief of Cardiac Surgery Cleveland Clinic FoundationProfessor of Surgery John Hopkins Hospital, Department of NeurologyProfessor of Neurology Massachusetts General HospitalProfessor of Surgery John Hopkins School of MedicineAssistant Professor of Medicine

Consultant
None

Speakers bureau
None

Personal research
None

Institutional, organizational, or other nancial benet


None None

Expert witness

Voting recusals by section numbers*


None

Loren F. Hiratzka

None

None

None

None

None

None

None

Adolph M. Hutter, Jr Michael E. Jessen Ellen C. Keeley Stephen J. Lahey

None

None

None

None

None

None

None

 Quest Medicalz None

None

None

None

None

None

2.1.8

None

None

None

None

None

None

None

None

None

None

None

Richard A. Lange

None

None

None

None

None

 Defendant, mitral valve replacement, 2009 None

None

None

Martin J. London

None

None

None

None

None

None

None

Michael J. Mack

Manesh R. Patel John D. Puskas Joseph F. Sabik Ola Selnes

Cordis Marquett Medtronic Edwards Lifesciencesz None

   

None

None

None

None

None

2.1.3 2.2.1 5.2.1.1 5.2.1.2 None

None

None

None

None

None

 Marquett  Medtronic  Edwards Lifesciences  Medtronic None

None

None

 Marquetty  Medtronicy None

None

None

None

None

None

None

None

None

None

None

None

2.1.3 2.2.1 2.2.2 2.2.2 5.2.1.1 5.2.1.2 None

David M. Shahian Jeffrey C. Trost

None

None

None

None

None

None

None

None

None

None

 Toshibay

None

None

2.1.7 3.5 4.10 4.10.1 4.10.2 4.10.3 5.2.1.1.1 5.2.1.1.2 (Continued)

The Journal of Thoracic and Cardiovascular Surgery c Volume 143, Number 1

31

Clinical Guideline

Hillis et al

APPENDIX 1. Continued
Ownership/ partnership/ principal
None

Committee member
Michael D. Winniford

Employer/title
University of Mississippi Medical CenterProfessor of Medicine

Consultant
None

Speakers bureau
None

Personal research
None

Institutional, organizational, or other nancial benet


None None

Expert witness

Voting recusals by section numbers*


None

This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reect relationships with industry at the time of publication. A person is deemed to have a signicant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. Relationships that exist with no nancial benet are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACCF/AHA, a person has a relevant relationship IF: (a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or (b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or (c) the person or a member of the persons household, has a reasonable potential for nancial, professional or other personal gain or loss as a result of the issues/content addressed in the document. AVR, Aortic valve replacement; CABG, coronary artery bypass graft surgery; and IABP, intra-aortic balloon pump. *Writing committee members are required to recuse themselves from voting on sections to which their specic relationships with industry and other entities may apply. Section numbers apply to the full-text guideline. ySignicant relationship. zNo nancial benet.

APPENDIX 2. Reviewer relationships with industry and other entitites (relevant)2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery
Ownership/ partnership/ principal None Institutional, organizational, or other nancial benet None None

Peer reviewer Robert Guyton

Representation Ofcial Reviewer ACCF/AHA Task Force on Practice Guidelines Ofcial Reviewer ACCF/AHA Task Force on Data Standards Ofcial Reviewer AHA Ofcial Reviewer ACCF/AHA Task Force on Performance Measures Ofcial Reviewer AHA Ofcial Reviewer ACCF Board of Governors Ofcial Reviewer ACCF Board of Trustees Organizational ReviewerSTS Organizational ReviewerAATS

Consultant None

Speakers bureau None

Personal research
 Edwards Lifesciences

Expert witness

Jeffrey Jacobs

None

None

None

None

None

None

L. Kristin Newby Eric D. Peterson

 AstraZeneca  AstraZeneca

None None

None None

 Eli Lilly*  GlaxoSmithKliney  BMS/sanoaventisy  Eli Lillyy

None None

None None

Richard J. Shemin Hector Ventura

 Edwards Lifesciences

None
 Actelion  Gilead

None None

None None

None None

None None

None

Thad F. Waites

None

None

None

None

None

None

T. Bruce Ferguson, Jr Stephen E. Fremes

None None

None None

None None

None None

None Merck

None
 Defendant, leaking thoracic aortic aneurysm, 2009  Defendant, aortic dissection, 2009

Colleen G. Koch Harold L. Lazar

Organizational ReviewerSCA Organizational ReviewerAATS

None None

None None

None None

None None

None None

None None (Continued)

32

The Journal of Thoracic and Cardiovascular Surgery c January 2012

Hillis et al

Clinical Guideline

APPENDIX 2. Continued
Ownership/ partnership/ principal None None None None Institutional, organizational, or other nancial benet None None None
 Plaintiff, communication of echocardiography results, 2010

Peer reviewer Walter H. Merrill Stanton K. Shernan

Representation Organizational ReviewerSTS Organizational ReviewerSCA

Consultant None None

Speakers bureau None


 Philips Healthcare

Personal research

Expert witness

Joseph S. Alpert Robert M. Califf

Content Reviewer Content Reviewer

      

Bayer Sano-aventis AstraZeneca Daiichi-Sankyo GlaxoSmithKline Medtronic Sano-aventis

None None

None None

None
 Eli Lillyy  Bayer

None None

None None

Robbin G. Cohen

Content Reviewer

None

None

None

None

None

Mark A. Creager

Content Reviewer ACCF/AHA Task Force on Practice Guidelines Content Reviewer ACCF/AHA Task Force on Practice Guidelines Content Reviewer

    

AstraZeneca Genzyme Merck Roche Vascutek

None

None

 Merck

None

 Defendant, death after minimally invasive heart surgery, 2011  Defendant, diagnosis of aortic dissection, 2010  Plaintiff, renal failure and Aprotinin, 2010  Plaintiff, Fasudil Development: Asahi Pharma v Actelion, 2010

Steven M. Ettinger

None

None

None

 Medtronic

None

None

David P. Faxon

 Sano-aventis

None

None

None

None

 Defendant, cath vascular access site complication, 2009

Kirsten E. Fleischmann Lee Fleisher

Content Reviewer Content Reviewer

None None

None None

None None

None
 Pzer

None
 AstraZenecay

None
 Defendant, perioperative stroke, 2009  Defendant, Bayer Corp. Trasylol litigation, 2009 to 2011

Anthony P. Furnary Valentin Fuster John W. Hirshfeld, Jr Judith S. Hochman

Content Reviewer ACCF Surgeons Scientic Council Content Reviewer Content Reviewer Content Reviewer ACCF/AHA Task Force on Practice Guidelines Content Reviewer Content Reviewer Vice Chair, 2012 STEMI Guideline Writing Committee

None

None

None

None

None

None
 GlaxoSmithKline  Eli Lilly  GlaxoSmithKline

None None None

None None None

None None None

None None None

None None None

James L. Januzzi, Jr Frederick G. Kushner

 Roche

None None

None None

 Roche

None None

None None

None

None

(Continued)

The Journal of Thoracic and Cardiovascular Surgery c Volume 143, Number 1

33

Clinical Guideline

Hillis et al

APPENDIX 2. Continued
Ownership/ partnership/ principal None None Institutional, organizational, or other nancial benet None None

Peer reviewer Glenn Levine

Representation Content Reviewer Chair, 2011 PCI Guideline Writing Committee Content Reviewer Content Reviewer Southern Thoracic Surgical Association

Consultant None

Speakers bureau None

Personal research

Expert witness

Donald Likosky James J. Livesay

None None

None None

None None

 Maquety  Medtronicy

None None

None
 Defendant, acute aortic dissection, 2011  Defendant, cardiac mortality review, 2010  Defendant, heparin induced thrombocytopenia, 2010

None

Bruce W. Lytle

Robert A. Marlow

Rick A. Nishimura Patrick OGara

E. Magnus Ohman

Content Reviewer 2004 CABG Guideline Writing Committee Content Reviewer 2004 CABG Guideline Writing Committee Content Reviewer ACCF Board of Trustees Content Reviewer Chair, 2012 STEMI Guideline Writing Committee Content Reviewer ACCF/AHA Task Force on Practice Guidelines

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

 AstraZeneca  Bristol-Myers Squibb  Boehringer Ingelheim  Gilead Sciences  Merck  Pozen  Sano-aventis

 Boehringer Ingelheim  Gilead Sciences

None

 Daiichi-Sankyo  Datascope  Eli Lilly

None

None

John D. Rutherford George A. Stouffer Mathew Williams

Content Reviewer Content Reviewer

None None

None None

None None

None None

None None

None
 Defendant, review of malpractice claim, 2010

Content Reviewer ACCF Interventional Scientic Council

 Edwards Lifesciences  Medtronic

None

None

None

None

None

This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. It does not necessarily reect relationships with industry at the time of publication. A person is deemed to have a signicant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. A relationship is considered to be modest if it is less than signicant under the preceding denition. Relationships that exist with no nancial benet are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACCF/AHA, a person has a relevant relationship IF: (a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or (b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or (c) the person or a member of the persons household, has a reasonable potential for nancial, professional or other personal gain or loss as a result of the issues/content addressed in the document. AATS, American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; CABG, coronary artery bypass graft surgery; PCI, percutaneous coronary intervention; SCA, Society of Cardiovascular Anesthesiologists; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons. *No nancial benet. ySignicant relationship.

34

The Journal of Thoracic and Cardiovascular Surgery c January 2012